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Campylobacter jejuni and Campylobacter coli infections are the leading cause of foodborne gastroenteritis in high-income countries. Campylobacter colonizes a variety of warm-blooded hosts that are reservoirs for human campylobacteriosis. The proportions of Australian cases attributable to different animal reservoirs are unknown but can be estimated by comparing the frequency of different sequence types in cases and reservoirs. Campylobacter isolates were obtained from notified human cases and raw meat and offal from the major livestock in Australia between 2017 and 2019. Isolates were typed using multi-locus sequence genotyping. We used Bayesian source attribution models including the asymmetric island model, the modified Hald model, and their generalizations. Some models included an "unsampled" source to estimate the proportion of cases attributable to wild, feral, or domestic animal reservoirs not sampled in our study. Model fits were compared using the Watanabe-Akaike information criterion. We included 612 food and 710 human case isolates. The best fitting models attributed >80% of Campylobacter cases to chickens, with a greater proportion of C. coli (>84%) than C. jejuni (>77%). The best fitting model that included an unsampled source attributed 14% (95% credible interval [CrI]: 0.3%-32%) to the unsampled source and only 2% to ruminants (95% CrI: 0.3%-12%) and 2% to pigs (95% CrI: 0.2%-11%) The best fitting model that did not include an unsampled source attributed 12% to ruminants (95% CrI: 1.3%-33%) and 6% to pigs (95% CrI: 1.1%-19%). Chickens were the leading source of human Campylobacter infections in Australia in 2017-2019 and should remain the focus of interventions to reduce burden., (© 2023 The Authors. Risk Analysis published by Wiley Periodicals LLC on behalf of Society for Risk Analysis.)

In this study we aimed to assess the utility of following up historical hepatitis C notifications for enhanced surveillance and linking cases to further testing and treatment. Queensland hepatitis C notifications from June 2018, 2013, 2008 and 2003 who were not incarcerated at the time of testing were followed up. The most recent identified clinicians for cases were contacted by telephone. When no information about a current clinician was available, the case was contacted via a letter or text message. Clinicians and cases were encouraged to pursue further testing and treatment and provide information about management. Following notification but prior to this study's follow-up, a majority of cases (309/532; 58%) had a negative polymerase chain reaction (PCR) test or underwent treatment.Clinician follow-up was successful in 21% of eligible cases, with the proportion decreasing with increasing time since notification. In conclusion, contacting clinicians to link notified cases to further testing and treatment may increase testing and treatment in a small proportion of cases notified up to nine years post-notification. From our experience, the follow-up of notifications before this time is unlikely to result in improved outcomes., (© Commonwealth of Australia CC BY-NC-ND)

Australia's goal of eliminating hepatitis C by 2030 requires increases in uptake of and access to testing and treatment. As hepatitis C is a notifiable condition, health departments have access to information about people exposed to the hepatitis C virus (HCV), including the details of notifying clinicians who ordered their diagnostic pathology tests. Hepatitis C RNA testing confirms active infection that requires treatment, whereas a positive antibody test result only indicates prior exposure to the virus. We undertook a pilot project in Queensland to follow up hepatitis C notifications with clinicians, aiming to increase HCV-RNA testing and treatment uptake. For all individuals with a first-time hepatitis C notification in Queensland between 3 November 2020 and 28 May 2021, we sought information regarding hepatitis C RNA testing from laboratories, excluding those cases diagnosed in prisons. Cases who did not have RNA testing identified as part of or after their initial diagnostic tests were followed up via their notifying clinician. Interviews with selected clinicians were undertaken to improve our understanding of the follow-up process. There were 769 new hepatitis C notifications during our study period: 244 had no subsequent RNA test identified and were followed up for this study. Of these, 134 cases were lost to follow-up; 26 were already being effectively case managed; 22 reported previous treatment and no further risk; and 62 were eligible for HCV-RNA testing. Twenty-six cases subsequently started hepatitis C treatment. Thirty-four percent of notifications that required follow-up resulted from testing initially requested in hospital settings. Following up hepatitis C notifications can result in increased treatment rates; however, the process was resource-intensive and often failed to result in further contact between clinicians and patients. Our findings also highlight the importance of supporting better continuity of care between hospitals and community settings., (© Commonwealth of Australia CC BY-NC-ND)

Background: Antibiotic resistance is a global health crisis, with inappropriate antibiotic use often being linked to non-prescribed antibiotic dispensing practices. This study aimed to examine the perspectives of multiple stakeholders on the drivers and potential solutions for non-prescribed antibiotic dispensing in Ethiopian community drug retail outlets (CDROs). Despite the prescription only use policies, the practice remains prevalent in Ethiopia. Many factors are thought to contribute to this issue, although little research is available for non-urban settings., Methods: A phenomenological qualitative study was conducted. Pharmacy professionals (owners or employees) working in non-urban towns CDROs were selected through a simulated client study, which identified CDROs that had dispensed antibiotics without a prescription. Some high-level decision makers in the Ethiopian health system were also purposively selected. Interviews were conducted in-person and over the phone or via Zoom. The interview data were transcribed verbatim, translated to English, and thematically analysed. NVivo 12 software was used to assist with coding., Results: CDRO pharmacy professionals (n = 18) and five decision makers were interviewed. Most professionals (61%) were pharmacists working in drug stores, with one to 11 years of work experience. Several contributing factors were identified at the level of patients, CDRO staff, and the healthcare system. These included economic interests, inadequate knowledge and inappropriate attitudes about antibiotic use or supply, and issues within the healthcare system included inaccessibility and insufficient capacity, absence of or a weak enforcement of prescription-only regulations or service supervision. Additionally, patient-related factors included a lack of knowledge and inappropriate attitudes about antibiotics use and their supply, previous successful treatment experience and a culture of seeking out antibiotics., Conclusions: A complex set of modifiable factors related to patients, CDRO staff and healthcare system were identified that contribute to the non-prescribed supply of antibiotics. Due to this complexity, a single solution will not resolve the issues. Therefore, a range of multifaceted solutions have been suggested, including stricter regulation, increasing availability and accessibility of healthcare services, collaboration, and local consensus-building among CDROs, regular training for CDRO staff, and using community social events to educate the public about responsible use of antibiotics., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Introduction: During the first two years of the COVID-19 pandemic, Australia implemented a series of international and interstate border restrictions. The state of Queensland experienced limited COVID-19 transmission and relied on lockdowns to stem any emerging COVID-19 outbreaks. However, early detection of new outbreaks was difficult. In this paper, we describe the wastewater surveillance program for SARS-CoV-2 in Queensland, Australia, and report two case studies in which we aimed to assess the potential for this program to provide early warning of new community transmission of COVID-19. Both case studies involved clusters of localised transmission, one originating in a Brisbane suburb (Brisbane Inner West) in July-August 2021, and the other originating in Cairns, North Queensland in February-March 2021., Materials and Methods: Publicly available COVID-19 case data derived from the notifiable conditions (NoCs) registry from the Queensland Health data portal were cleaned and merged spatially with the wastewater surveillance data using statistical area 2 (SA2) codes. The positive predictive value and negative predictive value of wastewater detection for predicting the presence of COVID-19 reported cases were calculated for the two case study sites., Results: Early warnings for local transmission of SARS-CoV-2 through wastewater surveillance were noted in both the Brisbane Inner West cluster and the Cairns cluster. The positive predictive value of wastewater detection for the presence of notified cases of COVID-19 in Brisbane Inner West and Cairns were 71.4% and 50%, respectively. The negative predictive value for Brisbane Inner West and Cairns were 94.7% and 100%, respectively., Conclusions: Our findings highlight the utility of wastewater surveillance as an early warning tool in low COVID-19 transmission settings.

Objectives: This review aimed to identify factors in the policymaking environment that influence a Health in all Policies approach in local government, how these vary across different municipal contexts, and the extent that theories of the policy process are applied., Methods: A scoping review was conducted to include sources published in English, between 2001 and 2021 in three databases, and assessed for inclusion by two blind reviewers., Results: Sixty-four sources were included. Sixteen factors of the policy process were identified, expanding on previously reported literature to include understanding and framing of health, use of evidence, policy priority, and influence of political ideology. Eleven sources applied or referred to theories of the policy process and few reported findings based on different local government contexts., Conclusion: There are a range of factors influencing a Health in All Policies approach in local government, although a limited understanding of how these differ across contexts. A theory-informed lens contributed to identifying a breadth of factors, although lack of explicit application of theories of the policy process in studies makes it difficult to ascertain meaningful synthesis of the interconnectedness of these factors., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Lilly, Kean, Hallett, Robinson and Selvey.)

Objectives: Non-prescription dispensing of antibiotics significantly contributes to widespread antibiotic misuse, which in turn hastens the occurrence of antibiotic resistance. It is believed to be common in Ethiopia despite prescription-only regulations. We aimed to quantify non-prescription dispensing of antibiotics in community drug retail outlets (CDROs) with a focus on non-urban towns in the Amhara region of Ethiopia., Methods: A multicentre simulated client (SC) study was conducted to measure the non-prescription provision of antibiotics in 225 consenting CDROs. Each CDRO was visited twice by two trained SCs, one to present pre-prepared clinical case scenarios and the other to directly request specific antibiotics. Descriptive statistical analysis was performed to report the findings., Results: The study had 450 interactions across the two visits. Non-prescribed antibiotics were obtained in 198 (88%) of the 225 clinical case scenarios-based visits and in 205 (91%) of the 225 direct antibiotic request visits. Most of the supply was at the first level of demand: 84% of the 198 clinical case scenario visits and 95% of the 205 direct antibiotic request visits. CDRO staff requested further information about the patient or the case in 40% of the clinical case scenarios-based visits and 30% of the direct antibiotic request visits., Conclusions: It was possible to obtain antibiotics without prescription from a high proportion of CDROs, both in clinical scenario-based and direct antibiotic request interactions. Multifaceted interventions including stringent regulatory enforcement, frequent CDRO practice surveillance, CDRO staff training and community health education are needed with greater emphasis on rural areas., (© The Author(s) 2022. Published by Oxford University Press on behalf of British Society for Antimicrobial Chemotherapy.)

Background: We aimed to identify risk factors for sporadic campylobacteriosis in Australia, and to compare these for Campylobacter jejuni and Campylobacter coli infections., Methods: In a multi-jurisdictional case-control study, we recruited culture-confirmed cases of campylobacteriosis reported to state and territory health departments from February 2018 through October 2019. We recruited controls from notified influenza cases in the previous 12 months that were frequency matched to cases by age group, sex, and location. Campylobacter isolates were confirmed to species level by public health laboratories using molecular methods. We conducted backward stepwise multivariable logistic regression to identify significant risk factors., Results: We recruited 571 cases of campylobacteriosis (422 C. jejuni and 84 C. coli) and 586 controls. Important risk factors for campylobacteriosis included eating undercooked chicken (adjusted odds ratio [aOR] 70, 95% CI 13-1296) or cooked chicken (aOR 1.7, 95% CI 1.1-2.8), owning a pet dog aged < 6 months (aOR 6.4, 95% CI 3.4-12), and the regular use of proton-pump inhibitors in the 4 weeks prior to illness (aOR 2.8, 95% CI 1.9-4.3). Risk factors remained similar when analysed specifically for C. jejuni infection. Unique risks for C. coli infection included eating chicken pâté (aOR 6.1, 95% CI 1.5-25) and delicatessen meats (aOR 1.8, 95% CI 1.0-3.3). Eating any chicken carried a high population attributable fraction for campylobacteriosis of 42% (95% CI 13-68), while the attributable fraction for proton-pump inhibitors was 13% (95% CI 8.3-18) and owning a pet dog aged < 6 months was 9.6% (95% CI 6.5-13). The population attributable fractions for these variables were similar when analysed by campylobacter species. Eating delicatessen meats was attributed to 31% (95% CI 0.0-54) of cases for C. coli and eating chicken pâté was attributed to 6.0% (95% CI 0.0-11)., Conclusions: The main risk factor for campylobacteriosis in Australia is consumption of chicken meat. However, contact with young pet dogs may also be an important source of infection. Proton-pump inhibitors are likely to increase vulnerability to infection., (© 2022. The Author(s).)

Background: Aboriginal and Torres Strait Islander Australians have disproportionately high rates of hepatitis C infection. Aboriginal Community Controlled Health Services play an important role in promoting hepatitis C treatment, but uptake is variable. This study explores the service-level barriers and enablers to hepatitis C screening and treatment among clients of Aboriginal Community Controlled Health Services in South East Queensland., Methods: This qualitative study involved yarns with 16 clients and 40 healthcare providers. Thematic analysis was used to identify common barriers and enablers to hepatitis C screening and treatment., Results: Common barriers included healthcare providers' knowledge deficits and inaccurate perceptions of clients' ability to complete treatment, whereas clients described stigma that resulted in distrust of health care, and experiences of poor relationships and connections with healthcare providers. Enablers included Aboriginal governance of Aboriginal Community Controlled Health Services and the ease of direct-acting antiviral treatment., Conclusions: This study's findings point to the need for healthcare worker training focussing on client autonomy, reduced hepatitis C-related stigma, and consideration of clinicians' roles in increasing service engagement. Addressing the barriers to hepatitis C treatment through client-focussed service improvement may promote increased hepatitis C screening and treatment among Aboriginal and Torres Strait Islander Australians.

The objective of this study is to determine the impacts of low-intensity heat on human health in regions with hot, humid summers. Current literature has highlighted an increase in mortality and morbidity rates during significant heat events. While the impacts on high-intensity events are established, the impacts on low-intensity events, particularly in regions with hot, humid summers, are less clear. A scoping review was conducted searching three databases (PubMed, EMBASE, Web of Science) using key terms based on the inclusion criteria. We included papers that investigated the direct human health impacts of low-intensity heat events (single day or heatwaves) in regions with hot, humid summers in middle- and high-income countries. We excluded papers written in languages other than English. Of the 600 publications identified, 33 met the inclusion criteria. Findings suggest that low-intensity heatwaves can increase all-cause non-accidental, cardiovascular-, respiratory- and diabetes-related mortality, in regions experiencing hot, humid summers. Impacts of low-intensity heatwaves on morbidity are less clear, with research predominantly focusing on hospitalisation rates with a range of outcomes. Few studies investigating the impact of low-intensity heat events on emergency department presentations and ambulance dispatches were found. However, the data from a limited number of studies suggest that both of these outcome measures increase during low-intensity heat events. Low-intensity heat events may increase mortality. There is insufficient evidence of a causal effect of low-intensity heat events on increasing morbidity for a firm conclusion. Further research on the impact of low-intensity heat on morbidity and mortality using consistent parameters is warranted., (© 2022. The Author(s).)

Introduction: Some evidence suggests that knowledge and attitudes towards rational antibiotic use influences dispensing practice in community drug retail outlets. However, there is limited evidence in resource limited countries, including Ethiopia. We aimed to assess the knowledge and attitudes surrounding antibiotic use or supply and antibiotic resistance, and the non-prescribed antibiotic dispensing practices in community drug retail outlets in non-urban Ethiopia., Methods: We conducted a cross-sectional survey of community drug retail outlet staff in the Amhara region, Ethiopia with a focus on non-urban towns. An expert validated self-administered questionnaire was used. Following exploratory factor analysis and best items selection, we summarised our findings and assessed factors associated with non-prescribed antibiotic dispensing. The data were analysed using Stata Statistical Software version 17. P-values < 0.05 were considered significant., Results: A total of 276 participants from 270 drug outlets completed the questionnaire. The participants median age was 30 (Interquartile range (IQR) = 25-35) years and 79.7% were pharmacy assistants. The majority demonstrated good levels of knowledge about antibiotic use or supply and antibiotic resistance (77.9% and 76% of the participants responded correctly to more than half of the items, respectively). We identified four attitude domains: the role of antibiotics in recovering from diseases regardless of their cause (median score = 2 (IQR = 2-4), beliefs inconsistent with good practice); professional competency to supply non-prescribed antibiotics, and the non-prescribed antibiotics supply (median score for each domain = 4 (IQR = 4-5), attitudes consistent with good practice); and positive attitudes towards actions to prevent antibiotic resistance and promote appropriate antibiotic use (median score = 4 (IQR = 4-5). Fifty eight percent of the participants reported that they had dispensed antibiotics without a prescription. Participants who did not perceive that they were competent to supply non-prescribed antibiotics (adjusted odds ratio = 0.86, 95% confidence interval = 0.78-0.93) were less likely to report non-prescribed antibiotics dispensing., Conclusion: While most of the participants had appropriate knowledge about and attitudes to antibiotic use and antibiotic resistance, basic knowledge and attitude gaps remain. Despite Ethiopia's regulatory restrictions, the non-prescribed antibiotic provision continues to be a common practice. Our study highlights the need for multifaceted interventions that may include a strict regulatory system, staff training and public education., (© 2022. The Author(s).)

There is a high degree of expert consensus that anthropogenic climate change will be catastrophic if urgent and significant measures to reduce carbon emissions are not undertaken worldwide. Australia is a world-leading exporter of coal and gas, and does not have an effective emissions reduction strategy. Though many Australians support action on climate change, this has not affected voting patterns. In this qualitative study, we aimed to explore the attitudes of Australian voters in Brisbane, Queensland, Australia towards potential environmental policies. We approached people in public spaces, and invited them to participate in interviews. Six of the thirty-five interview participants who voted for the two main political parties or were undecided voters agreed with the transition to 100% renewables and/or no new coal mines in Australia. Many thought that renewables were not reliable enough and/or the economy was too dependent on coal to make the transition. There was strong support for political leadership in order to regulate mining and pollution, and for a transition plan for fossil-fuel-dependent communities. Participants were most concerned about tangible environmental issues, such as waste and pollution, and also described needing clear solutions in order to engage with the issues. Some described feeling 'shouted at' by protests and messaging about climate change and environmental issues. Our findings suggest that solution-based messaging may increase levels of engagement about climate change, and that waste and pollution can be entry-points for discussions about climate change. It is important to have conversations with people about this important issue.

Western Australia criminalises sex work whilst some other Australian jurisdictions have decriminalised the industry. This article examines the role of Western Australia's legislation in reinforcing stigma and discrimination of sex workers. It draws on stigma and discrimination-specific results from open-ended survey responses and interview data collected as part of a larger cross-sectional mixed-methods study. Experiences and/or anticipation of stigma and discrimination resulted in some sex workers concealing their involvement in sex work from family, friends and their home communities. This was a major barrier to accessing health care and protective services and impacted negatively on their mental health and wellbeing. There is a need for policy change and support to shift society's perception of sex work to that of a legitimate occupation to decrease sex workers' experiences of stigma and discrimination and improve their access to and utilisation of health care and protective services. These findings highlight the need for the decriminalisation of the Western Australian sex industry and the development of training programmes for police and healthcare workers to reduce the stigma and discrimination experienced by sex workers in these settings.

Best practice in sex work research advocates for a 'nothing about us without us' methodology. This study employed sex workers as peer researchers to assist in evaluating the sexual health outcomes and well-being of sex workers in Western Australia. All eight peer researchers were invited to reflect on their experiences as peer researchers through semi-structured interviews, and seven peer researchers participated. Giving sex workers a voice and the opportunity to facilitate change for their peers was the primary driver for participation. Some peer researchers from English speaking backgrounds experienced challenges engaging and communicating with study participants for whom English was not their first language. Others experienced role conflict on hearing viewpoints contrary to their own beliefs. Access to support from the project team and other peer researchers was a key enabler for undertaking the peer researcher role. The majority of peer researchers were motivated to participate in the research by the possibility of future changes to sex work-related legislation, and support for sex workers based on the research findings. Research partnerships with peer researchers that offer employment throughout the research process, including co-authorship of journal articles, opportunities for leadership roles and collaboration in research translation activities can increase research impact.

Background and Objectives: General practitioners (GPs) have an important role to play in increasing direct-acting antiviral (DAA) treatment for hepatitis C virus (HCV) among people who inject drugs (PWID). A stronger understanding of how GPs can support this group in the uptake and completion of DAA treatment is required., Method: A purposive sample of 27 patients (nine women and 18 men) with a history of HCV participated in semi-structured interviews capturing perspectives about the role of GPs in facilitating and supporting DAA treatment. Thematic analysis focused specifically on experiences of accessing treatment while continuing injecting drug use and how GPs can support uptake in PWID., Results: GPs need to prioritise and initiate discussions about HCV treatment with PWID. It is important that GPs provide clear and consistent information about the treatment journey; address myths of ineligibility and feelings of guilt and apathy towards treatment; and facilitate blood sampling, particularly for those with difficult venous access., Discussion: This study contributes to HCV prevention and treatment literature by providing insights into practical ways GPs can encourage uptake and completion of treatment with PWID.

Direct acting antiviral (DAA) treatment has made the elimination of hepatitis C virus (HCV) a realisable global public health goal and people who inject drugs are a key target population. This study investigates barriers and enablers to DAA treatment of HCV in general practice settings in Australia, from the patient perspective. Semi-structured interviews were conducted with 28 patients; of these patients, seventeen participants were currently on opioid agonist therapy, and four were currently injecting drugs. Thematic data analysis was undertaken and a personal, provider and systems framework was used to describe the barriers and enablers to DAA treatment. Results suggest a range of initiatives are required to support the uptake of DAA in general practice settings. These include the provision of formalised peer information and support, and increasing the accessibility of blood tests and liver assessment on-site. Further, there remains a need to address stigma and discrimination affecting people who inject drugs in community healthcare settings., (Copyright © 2021 Elsevier Inc. All rights reserved.)

CHAPTER 1: CHARACTERISING AUSTRALIA'S RURAL SPECIALIST PHYSICIAN WORKFORCE: THE PROFESSIONAL PROFILE AND PROFESSIONAL SATISFACTION OF JUNIOR DOCTORS AND CONSULTANTS: Objective: To assess differences in the demographic characteristics, professional profile and professional satisfaction of rural and metropolitan junior physicians and physician consultants in Australia., Design, Setting and Participants: Cross-sectional, population level national survey of the Medicine in Australia: Balancing Employment and Life longitudinal cohort study (collected 2008-2016). Participants were specialist physicians from four career stage groups: pre-registrars (physician intent); registrars; new consultants (< 5 years since Fellowship); and consultants., Main Outcome Measures: Level of professional satisfaction across various job aspects, such as hours worked, working conditions, support networks and educational opportunities, comparing rural and metropolitan based physicians., Results: Participants included 1587 pre-registrars (15% rural), 1745 physician registrars (9% rural), 421 new consultants (20% rural) and 1143 consultants (13% rural). Rural physicians of all career stages demonstrated equivalent professional satisfaction across most job aspects, compared with metropolitan physician counterparts. Some examples of differences in satisfaction included rural pre-registrars being less likely to agree they had good access to support and supervision from qualified consultants (odds ratio [OR], 0.6; 95% CI, 0.3-0.9) and rural consultants being more likely to agree they had a poorer professional support network (OR, 1.9; 95% CI, 1.2-2.9). In terms of demographics, relatively more rural physicians had a rural background or were trained overseas. Although most junior physicians were women, female consultants were less likely to be working in a rural location (OR, 0.6; 95% CI, 0.4-0.8)., Conclusion: Junior physicians in metropolitan or rural settings have a similar professional experience, which is important in attracting future trainees. Increased opportunities for rural training should be prioritised, along with addressing concerns about the professional isolation and poorer support network of those in rural areas, not only among junior doctors but also consultants. Finally, making rural practice more attractive to female junior physicians could greatly improve the consultant physician distribution. CHAPTER 2: GENERAL PHYSICIANS AND PAEDIATRICIANS IN RURAL AUSTRALIA: THE SOCIAL CONSTRUCTION OF PROFESSIONAL IDENTITY: Objective: To explore the construction of professional identity among general physicians and paediatricians working in non-metropolitan areas., Design, Setting and Participants: In-depth qualitative interviews were conducted with general physicians and paediatricians, plus informants from specialist colleges, government agencies and academia who were involved in policy and programs for the training and recruitment of specialists in rural locations across three states and two territories. This research is part of the Training Pathways and Professional Support for Building a Rural Physician Workforce Study, 2018-19., Main Outcome Measures: Individual and collective descriptors of professional identity., Results: We interviewed 36 key informants. Professional identity for general physicians and paediatricians working in regional, rural and remote Australia is grounded in the breadth of their training, but qualified by location - geographic location, population served or specific location, where social and cultural context specifically shapes practice. General physicians and paediatricians were deeply engaged with their local community and its economic vulnerability, and they described the population size and dynamics of local economies as determinants of viable practice. They often complemented their practice with formal or informal training in areas of special interest, but balanced their practice against subspecialist availability, also dependent on demographics. While valuing their professional roles, they showed limited inclination for industrial organisation., Conclusion: Despite limited consensus on identity descriptors, rural general physicians and paediatricians highly value generalism and their rural engagement. The structural and geographic bias that preferences urban areas will need to be addressed to further develop coordinated strategies for advanced training in rural contexts, for which collective identity is integral. CHAPTER 3: SUSTAINABLE RURAL PHYSICIAN TRAINING: LEADERSHIP IN A FRAGILE ENVIRONMENT: Objectives: To understand Royal Australasian College of Physicians (RACP) training contexts, including supervisor and trainee perspectives, and to identify contributors to the sustainability of training sites, including training quality., Design, Setting and Participants: A cross-sectional mixed-methods design was used. A national sample of RACP trainees and Fellows completed online surveys. Survey respondents who indicated willingness to participate in interviews were purposively recruited to cover perspectives from a range of geographic, demographic and training context parameters., Main Outcome Measures: Fellows' and trainees' work and life satisfaction, and their experiences of supervision and training, respectively, by geographic location., Results: Fellows and trainees reported high levels of satisfaction, with one exception - inner regional Fellows reported lower satisfaction regarding opportunities to use their abilities. Not having a good support network was associated with lower satisfaction. Our qualitative findings indicate that a culture of undermining rural practice is prevalent and that good leadership at all levels is important to reduce negative impacts on supervisor and trainee availability, site accreditation and viability. Trainees described challenges in navigating training pathways, ensuring career development, and having the flexibility to meet family needs. The small number of Fellows in some sites poses challenges for supervisors and trainees and results in a blurring of roles; accreditation is an obstacle to provision of training at rural sites; and the overlap between service and training roles can be difficult for supervisors., Conclusion: Our qualitative findings emphasise the distinctive nature of regional specialist training, which can make it a fragile environment. Leadership at all levels is critical to sustaining accreditation and support for supervisors and trainees. CHAPTER 4: PRINCIPLES TO GUIDE TRAINING AND PROFESSIONAL SUPPORT FOR A SUSTAINABLE RURAL SPECIALIST PHYSICIAN WORKFORCE: Objective: To draw on research conducted in the Building a Rural Physician Workforce project, the first national study on rural specialist physicians, to define a set of principles applicable to guiding training and professional support action., Design: We used elements of the Delphi approach for systematic data collection and codesign, and applied a hybrid participatory action planning approach to achieve consensus on a set of principles., Results: Eight interconnected foundational principles built around rural regions and rural people were identified: FP1, grow your own "connected to" place; FP2, select trainees invested in rural practice; FP3, ground training in community need; FP4, rural immersion - not exposure; FP5, optimise and invest in general medicine; FP6, include service and academic learning components; FP7, join up the steps in rural training; and FP8, plan sustainable specialist roles., Conclusion: These eight principles can guide training and professional support to build a sustainable rural physician workforce. Application of the principles, and coordinated action by stakeholders and the responsible organisations, are needed at national, state and local levels to achieve a sustainable rural physician workforce., (© 2021 AMPCo Pty Ltd.)

Background: Non-prescription dispensing of antibiotics, one of the main sources of antibiotic misuse or over use, is a global challenge with detrimental public health consequences including acceleration of the development of antimicrobial resistance, and is facilitated by various intrinsic and extrinsic drivers. The current review aimed to systematically summarise and synthesise the qualitative literature regarding drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries., Methods: Four electronic databases (PubMed, CINAHL, Scopus and Google Scholar) and reference lists of the relevant articles were searched. The Joanna Briggs Institute's Critical Appraisal Checklist for qualitative studies was used to assess the quality of included studies. The enhancing transparency in reporting the synthesis of qualitative research statement was used to guide reporting of results. Data were coded using NVivo 12 software and analysed using both inductive and deductive thematic analysis., Results: A total of 23 articles underwent full text review and 12 of these met the inclusion criteria. Four main themes were identified in relation to facilitators of non-prescribed sale of antibiotics among community drug retail outlets: i) the business orientation of community drug retail outlets and tension between professionalism and commercialism; ii) customers' demand pressure and expectation; iii); absence of or a lax enforcement of regulations; and iv) community drug retail outlet staff's lack of knowledge and poor attitudes about antibiotics use and scope of practice regarding provision., Conclusions: This review identified several potentially amendable reasons in relation to over the counter dispensing of antibiotics. To contain the rise of antibiotic misuse or over use by targeting the primary drivers, this review suggests the need for strict law enforcement or enacting new strong regulation to control antibiotic dispensing, continuous and overarching refresher training for community drug retail outlet staff about antibiotic stewardship, and holding public awareness campaigns regarding rational antibiotic use.

Background: The development of antimicrobial resistance, which is partially attributable to the overuse and/or misuse of antibiotics in health care, is one of the greatest global public health challenges. In Sub-Saharan African (SSA) countries, non-prescribed dispensing of antibiotics in community drug retail outlets (CDROs) has been flagged as one of the contributing factors for the widespread misuse of antibiotics in the community., Objective: The current review aimed to estimate the proportion of non-prescription antibiotics requests or consultations that resulted in provision of antibiotics without a valid prescription among CDROs in SSA region, and describe the type of antibiotics dispensed., Methods: A literature search was conducted using PubMed, CINAHL, Scopus and Google Scholar. We also searched reference lists of relevant articles. Random effect model meta-analysis was employed to determine the pooled proportion of over the counter sale of antibiotics. Subgroup and meta-regression was undertaken to explore the potential cause of heterogeneity in effect size across studies., Results: Of 671 total citations retrieved, 23 met the inclusion criteria (seven cross-sectional questionnaire-based surveys and 16 cross-sectional client-based studies). The overall pooled proportion of non-prescription antibiotics requests or consultations that resulted in supply of antibiotics without prescription was 69% (95% CI 58-80). Upper respiratory tract infections and/or acute diarrhoea were the most frequently presented case scenarios, and amoxicillin and co-trimoxazole were the most frequently dispensed antibiotics to treat those symptoms., Conclusions: Non-prescribed dispensing of antibiotics was found to be a common practice among CDROs in several SSA countries. Ease of access to and overuse of antibiotics can potentially accelerate the emergence of resistance to antibiotics available in the region. Our review highlights the need for a stringent enforcement of existing policies and/or enacting new regulatory frameworks that would regulate antibiotic supply, and training and educational support for pharmacy personnel (e.g. pharmacists, pharmacy assistants) regarding judicious use of antibiotics and the importance of antimicrobial stewardship.

Introduction: Antimicrobial resistance is a global public health crisis. A major driver of resistance is inappropriate antibiotic use, resulting from practices of prescribers, dispensers and patients. The purpose of this study was to identify the perception of service providers and policymakers about the inappropriate use of antibiotics in Nepal., Methods: A qualitative study was conducted to explore factors influencing antibiotic use. Participants included 17 service providers and policymakers from the Rupandehi district in Nepal, with a semi-structured interview schedule adopted. Data were analysed using thematic analysis to identify themes relating to the inappropriate use of antibiotics., Results: Inappropriate use of antibiotics was found to result from the interaction of demand and supply factors, together with a weak regulatory environment. Lack of knowledge by consumers and financial constraints resulted in practices such as self-medication and pressure being placed on providers to prescribe or dispense antibiotics. An insufficient choice of antibiotics, and health services not having investigation facilities, was also factors leading to inappropriate use of antibiotics. Additionally, in the private sector, the profit motive arising from incentives provided by pharmaceutical companies contributed to prescribing or dispensing antibiotics inappropriately., Conclusion: Promoting appropriate antibiotic use is critical to reduce the growing public health threat of antibiotic resistance. A multi-faceted approach involving policymakers, providers, and the general public using both educational and regulatory measures is required to address this problem in Nepal, and potentially also in other low-income countries with a similar healthcare system., (© 2020 John Wiley & Sons Ltd.)

We undertook a scoping study to map the relevant evidence, summarise the findings, and to help identify gaps in the knowledge base on the relationship between land use/land-use change and human health in Australia. Our systematic search of the scientific literature for relevant articles up to August 2020 identified 37 articles. All 37 articles meeting our inclusion criteria were published after 2003. Zoonotic or vector-borne disease constituted the most common health outcome type studied. Agriculture/grazing was the land use/land-use change type most frequently represented in the literature, followed by coal seam gas extraction and open cut coal mining. The relationship between land use/land use change and human health in Australia, is not conclusive from the existing evidence. This is because of (1) a lack of comprehensive coverage of the topic, (2) a lack of coverage of the geography, (3) a lack of coverage of study types, and (4) conflicting results in the research already undertaken. If we are to protect human health and the ecosystems which support life, more high-quality, specific, end-user driven research is needed to support land management decisions in Australia. Until the health effects of further land use change are better known and understood, caution ought to be practiced in land management and land conversion.

To investigate factors that enable or challenge the initiation and actioning of health and wellbeing policy in Australian local governments using political science frameworks. An online survey was distributed to staff and elected members of Australian local governments. The survey sought responses to a range of variables as informed by political science frameworks. Data were analysed using descriptive statistics and results were compared between local governments of different geographical sizes and locations using Kruskal-Wallis non-parametric testing. There were 1825 survey responses, including 243 CEOs, representing 45% of Australian local governments. Enablers for local government policy initiation and action included the high priority given to health and wellbeing (44%), local leadership (56%) and an organizational (70%) and personal obligation (68%) to the community to act. Less true is a favourable legislative environment (33%), leadership from higher levels of government (29%) and sufficient financial capacity (22%). Cities are better positioned to initiate and action health policy, regardless of the broader legislative environment. Health and wellbeing is a high priority for Australian local governments, despite lack of funding and limited lobbying and support from other sectors and higher levels of government. The insights from political science frameworks assist to understand the policy process, including the interrelatedness of enablers and challenges to initiating and actioning health and wellbeing policy. Further understanding the policy drivers would support practitioners and researchers advocating to influence local health and wellbeing policy., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: The recent implementation of a scheme to provide universal access to direct-acting antiviral (DAA) medication to treat hepatitis C virus (HCV) places Australia in a unique position to reach global HCV elimination goals. To achieve this, increasing the uptake and success of DAA treatment in general practice settings is essential., Aims: To explore current enablers and residual barriers to HCV treatment in general practice settings in the post-interferon era from both general practitioner (GP) and patient perspectives., Methods: Semi-structured interviews with 11 GP and 27 patients were conducted to draw out both challenges and facilitators particularly relevant to DAA uptake and treatment journeys., Results: Key enablers for successful treatment identified by this study included peer-led GP support and skill development, utilisation of electronic reminder systems, trusting relationships with patients and engaging with patients' social and family networks. Barriers related to accessible testing facilities and knowledge and confidence with DAA treatment continue to limit GP-led treatment., Conclusions: Despite a universal access scheme, barriers to DAA prescription in general practice settings remain. These include access to fibrosis testing and GP confidence in DAA prescription. Strengthening peer-led GP skill development and utilisation of electronic reminder systems may help GP prioritise HCV treatment. Access to fibrosis testing and pathology services with no out-of-pocket costs to patients, particularly in outer-metropolitan areas, should be urgently addressed., (© 2019 Royal Australasian College of Physicians.)

Introduction: Human papillomavirus (HPV) vaccination is offered in Australia through school-based programs. While HPV vaccination coverage is high, coverage of the full course of vaccination is suboptimal in Australia and there is a drop in coverage between the first and third doses. This study aimed to describe the drivers of low HPV vaccination coverage in Western Australian (WA) schools and barriers and enablers to improving vaccine coverage. This paper focusses on process and system-level factors., Materials and Methods: This was a mixed methods study. We analysed WA vaccination coverage data by school, undertook an online survey targeting the individuals responsible for the HPV vaccination program in their schools and school nurses, and compared survey findings and HPV vaccine dose three coverage in schools with 50 or more students in the eligible cohort. We also conducted focus groups with students and interviews with parents in schools with low HPV vaccine coverage., Results: Schools with low HPV vaccine coverage had low coverage for the first dose of HPV vaccine as well as a higher drop off between first and third doses compared to schools with higher HPV vaccine coverage. Respondents from low and middle HPV vaccine coverage schools reported more issues with return of consent forms, low parental literacy, language barriers, absenteeism and difficulty contacting parents compared to schools with high coverage. Parents and students raised a number of challenges in relation to HPV vaccination including student absenteeism, language barriers, and issues with the return of consent forms., Conclusions: A multifaceted approach to improving HPV vaccination coverage should be targeted at schools with low coverage. Based on our findings, these actions should include a range of approaches to obtaining parental consent and intensive follow up with students who are absent on vaccination days., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

This study compares the frequency and severity of influenza A/H1N1pdm09 (A/H1), influenza A/H3N2 (A/H3) and other respiratory virus infections in hospitalised patients. Data from 17 332 adult hospitalised patients admitted to Sir Charles Gairdner Hospital, Perth, Western Australia, with a respiratory illness between 2012 and 2015 were linked with data containing reverse transcription polymerase chain reaction results for respiratory viruses including A/H1, A/H3, influenza B, human metapneumovirus, respiratory syncytial virus and parainfluenza. Of these, 1753 (10.1%) had test results. Multivariable regression analyses were conducted to compare the viruses for clinical outcomes including ICU admission, ventilation, pneumonia, length of stay and death. Patients with A/H1 were more likely to experience severe outcomes such as ICU admission (OR 2.5, 95% CI 1.2-5.5, P = 0.016), pneumonia (OR 3.0, 95% CI 1.6-5.7, P < 0.001) and lower risk of discharge from hospital (indicating longer lengths of hospitalisation; HR 0.64 95% CI 0.47-0.88, P = 0.005), than patients with A/H3. Patients with a non-influenza respiratory virus were less likely to experience severe clinical outcomes than patients with A/H1, however, had similar likelihood when compared to patients with A/H3. Patients hospitalised with A/H1 had higher odds of severe outcomes than patients with A/H3 or other respiratory viruses. Knowledge of circulating influenza strains is important for healthcare preparedness.

Background: The development of antibiotic resistance is one of the biggest threats to global public health. Inappropriate use of antibiotics is recognised as a leading cause of antibiotic resistance. The aim of this study was to explore the knowledge, attitudes and practices (KAP) towards antibiotic use among adults in Nepal., Methods: A quantitative survey was conducted with 220 community members of the Rupandehi district of Nepal, with cluster sampling techniques applied to select households. Interviews were carried out face-to-face using a structured questionnaire. Responses were presented using descriptive analysis, with chi-squared tests and regression analysis applied to identify factors associated with KAP about antibiotic use and the Spearman's rank order correlation coefficient calculated to examine the relationship between responses to the KAP questions., Results: The sample comprised more females (54%) than males, the average age of respondents was 38.5 years and almost 60% of respondents lived in rural areas. Respondents had relatively good knowledge about aspects of antibiotic use other than identifying antibiotics. The concept of antibiotic resistance was well known but imperfectly understood. Half of respondents (50.9%) were unsure whether skipping doses would contribute to the development of antibiotic resistance, 88.2% indicated they would go to another doctor if not prescribed an antibiotic when they thought one was needed and nearly half (47.7%) believed antibiotics helped them get better more quickly if they had a fever. Most respondents reported correct practices accessing and using antibiotics, however, 84.6% at least sometimes preferred an antibiotic when they have a cough and sore throat. Logistic regression showed respondents with higher levels of education tended to have better knowledge, more appropriate attitudes and better practices about antibiotic use. Rural respondents were less likely to have better knowledge about antibiotic use, while females were more likely to report better practices., Conclusion: The study provides baseline evidence about the knowledge, attitudes and practices regarding antibiotic use among the population of the Rupandehl district. Its findings will be useful in designing effective and targeted interventions to decrease misconceptions about antibiotic use and to increase awareness about the risks of inappropriate use of antibiotics in the community.

Objectives: Private pharmacies are widely established in most low/middle-income countries (LMICs) including Nepal, and are often considered as a patient's first point of contact for seeking healthcare. The aim of this study was to investigate the pattern of antibiotic dispensing in private pharmacies through exit interviews with patients to review their medication information., Design and Setting: Cross-sectional study. Data collection was carried out in 60 days at 33 randomly selected private pharmacies in the Rupandehi district of Nepal., Participants: Patients attending private pharmacies (n=1537)., Main Outcome Measure: The pattern of antibiotic prescribing and dispensing was investigated using WHO's core prescribing indicator, ' the percentage of patients prescribed an antibiotic' . Frequency distributions were presented based on patients' characteristics, sources of antibiotic, registration status of pharmacies and education of the pharmacist or drug retailer, and disease or condition. χ 2 tests and regression analysis were applied to explore factors associated with the pattern of antibiotic dispensing., Results: Of patients attending private pharmacies, the proportion receiving at least one antibiotic (38.4%) was above the WHO recommended value (20.0%-26.8%). The most commonly dispensed antibiotics were cefixime (16.9%) and the third-generation cephalosporins (38.0%) class. High dispensing rates of antibiotics for selected conditions (eg, respiratory infections, diarrhoeal cases) appeared contrary to international recommendations. The percentage of antibiotic dispensed was highest for patients who obtained their medicines from unlicensed pharmacies (59.1%). Young people were more likely to receive antibiotics than other age groups., Conclusions: The antibiotic dispensing pattern from private pharmacies in Nepal was high compared with WHO guidelines, suggesting initiatives to reduce inappropriate use of antibiotics should be implemented. The findings of this study may be generalisable to other LMICs in order to assist in developing policies and guidelines to promote more appropriate dispensing and prescribing practices of antibiotics and limit the spread of antibiotic resistance., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background There is limited information available about the health and wellbeing of male sex workers in Australia and globally. This study therefore was conducted to survey male sex workers in Western Australia as part of a broader study investigating the health and safety of sex workers in Western Australia., Methods: Male sex workers were surveyed using a modified survey instrument that had been used in a study undertaken in 2006. Survey respondents were recruited by word-of-mouth, social media, advertisements in gay press and in person. In-depth interviews with a small number of male sex workers were also conducted., Results: Fifty-eight men responded to the survey. The majority of survey respondents (42/58, 72%) were aged ≤35 years and a high proportion (50/58, 86%) worked privately at least some of the time. Seventy-two per cent (33/46) reported consistently using condoms during anal sex and 22% (11/51) during oral sex with clients. The consistent use of condoms with partners outside of work was associated with consistent use of condoms with clients. Forty per cent (23/58) of respondents reported currently using tobacco and 47% (25/53) reported harmful drinking at least weekly. The majority of respondents reported that sex work enhanced their wellbeing, with negative effects being largely due to stigma and discrimination, and the uncertainty related to not having a steady income., Conclusion: The study findings point to the need for peer outreach and support, interventions to improve the broader health of male sex workers and decriminalisation of sex work in Western Australia.

Noise presents an ongoing occupational health and safety issue, which despite numerous studies still presents a significant risk in agriculture with high exposures prevalent. In this study, we measured noise exposures associated with significant activities on 42 mixed grain and livestock farms in Western Australia. Employing a mixture of personal noise measurements using dosimeters, noise measurements using sound level meters, and a validated survey, we identified that 32% of farm workers were exposed to noise levels above the LAeq,8h 85 dB(A) limit, before considering extended shifts. We also noted that extended shift lengths, of up to 16 h in some cases, were possible. In addition, we found that 37% of workers were exposed to noise peak of 140 dB(C) or greater. It was further noted that hearing protection is not typically worn for the duration of an activity and is only for a small number of tasks. However we did find some evidence that farmers had begun to implement some form of noise management practice, usually in the form of buying quieter equipment or separating noisy tasks from quiet tasks. Improved education for farmer and farm workers in terms of the risks posed by noise, identifying noisy tasks, is recommended, as well as a programme to encourage better and consistent use of hearing protection., (© The Author(s) 2018. Published by Oxford University Press on behalf of the British Occupational Hygiene Society.)

Background: Management of a cleft of the lip and/or palate (CL/P) involves a multidisciplinary team approach lasting from birth to potentially postskeletal maturity. This condition is complex, with both medical and psychosocial implications that may place individuals with a cleft at higher risk of developing psychosocial problems., Methodology: A self-administered questionnaire was completed by a sample from the Western Australian cleft population comprising 3 age groups: child (n = 100), adolescent (n = 101), and adult (n = 158)., Results: Public speaking, being photographed, special relationships, and participation in school were identified as the areas most impacted by having a cleft. Hearing and speech were reported to have a higher importance than facial and dental appearance. Participants rated support given to them by their parents as the most important, with high ratings for treatment providers. For teasing, the impact of cleft was significantly higher among participants with cleft lip and palate for both the adolescent and adult age groups. There was little significant difference by gender across the variables, which suggests that males are just as likely to require support as females., Conclusion: The impact of a cleft across multiple psychosocial domains needs to be recognized and addressed as part of craniofacial team care across age groups.

Agricultural operations routinely expose farm workers to high levels of soil dust and other airborne particulate matter that have been linked to adverse health outcomes. The main objective of this study was to investigate exposure to agricultural dust during seeding operations of Western Australian farm workers. Twenty-one wheat-belt farms were recruited to participate in the study. Data were collected over the 6-week seeding period of April-June 2014. Each farm was visited once, and workers were asked to complete a workplace survey that asked questions related to minimizing exposure to agricultural dusts and occupational health and safety issues on their farm. Farmers were also asked to simultaneously participate in monitoring of personal exposure to inhalable or respirable dust along with real-time monitoring for particulate air pollution in their tractor cabin. Sampling was undertaken for 4 hr. The results showed that, on average, Western Australian farmers were exposed to personal respirable dust concentrations above the Australian Institute of Occupational Hygienists recommended guideline values, with some farmers being exposed to concentrations up to seven times higher than the value for respirable dusts. In comparison, in-cabin dust concentrations were lower, although some individual tractors recorded intermittently higher levels, which might be attributed to the type of work activity or process being undertaken. Remaining in tractor cabins with closed doors and windows with properly maintained seals might minimize the infiltration of hazardous dusts and may provide some protection from dust exposures. Future research should focus on educating and providing farm owners and workers with more information on adopting work processes and procedures related to minimizing harmful exposures to agricultural dusts.

Introduction: Since the emergence of the HIV pandemic in the 1980s, high rates of condom use for penetrative sex have been reported among sex workers in Australia. The sex industry in Australia and elsewhere has changed over the previous decade with increasing proportions of sex workers working privately and lower proportions of sex workers working in brothels. There has also been some evidence of reductions in condom use, particularly during penetrative oral sex. We therefore decided to investigate sex workers' use of condoms during penetrative sex with clients. Methods: This was a cross-sectional mixed methods study of sex workers in Western Australia. The study involved an environmental scan of the sex industry in Western Australia, visits to brothels and other sexual services premises, a survey of sex workers and in-depth interviews. Results: We surveyed 354 male, female, and transgender sex workers in Western Australia. We found unexpectedly low rates of reported condom use with clients for all forms of penetrative sex. Of respondents who reported providing this type of service, 33% reported that all clients used condoms during oral sex, 69% during vaginal sex and 59% during anal sex. High levels of client demand for condomless sex was also reported, with 42% of sex workers reporting that all or most clients requested condomless oral sex. Increasing client demand, fear of losing clients and the ability to charge more for condomless sex were reported reasons for providing this service. Conclusions: There has been an apparent increase in sex workers reporting condomless penetrative sex with clients in Western Australia compared to a previous cross-sectional study. An increase in private sex work and client demand for condomless sex together with an economic downturn leading to increased competition for clients may be important contributing factors.

Introduction Despite a range of interventions, annual numbers of new diagnoses of HIV infection among men who have sex with men (MSM) in Australia have not declined in recent years. Peer-based sexual health clinics targeting MSM, such as the M Clinic in Perth (WA, Australia), have been put in place to provide safe sex counselling and to increase testing rates among MSM and who are at high risk of HIV infection. The aim of this study was to assess the incidence of HIV, chlamydia and gonorrhoea among men attending the M Clinic., Methods: This was a historical cohort study of repeated M Clinic clients from January 2011 to June 2015 inclusive. Testing and risk factor data from M Clinic client software were used to estimate the incidence of HIV, chlamydia and gonorrhoea and associated factors., Results: The incidence of HIV, chlamydia and gonorrhoea was 1.87, 13.58 and 6.48 per 100 person-years respectively. Older men had a higher incidence of HIV infection but a lower incidence of chlamydia and gonorrhoea than younger men., Conclusions: The HIV incidence was higher than found in similar studies in other Australian sexual health clinics, but the incidence of chlamydia and gonorrhoea was similar. The high HIV incidence among clients of the M Clinic points to the importance of making pre-exposure HIV prophylaxis available to clients of the M Clinic and similar services.

Mosquito and virus surveillance systems are widely used in Western Australia (WA) to support public health efforts to reduce mosquito-borne disease. However, these programs are costly to maintain on a long-term basis. Therefore, we aimed to assess the validity of mosquito numbers and Ross River virus (RRV) isolates from surveillance trap sites as predictors of human RRV cases in south-west WA between 2003 and 2014. Using negative binomial regression modeling, mosquito surveillance was found to be a useful tool for predicting human RRV cases. In eight of the nine traps, when adjusted for season, there was an increased risk of RRV cases associated with elevated mosquito numbers detected 1 month before the onset of human cases for at least one quartile compared with the reference group. The most predictive urban trap sites were located near saltmarsh mosquito habitat, bushland that could sustain macropods and densely populated residential suburbs. This convergence of environments could allow enzootic transmission of RRV to spillover and infect the human population. Close proximity of urban trap sites to each other suggested these sites could be reduced. Ross River virus isolates were infrequent at some trap sites, so ceasing RRV isolation from mosquitoes at these sites or where isolates were not predictive of human cases could be considered. In future, trap sites could be reduced for routine surveillance, allowing other environments to be monitored to broaden the understanding of RRV ecology in the region. A more cost-effective and efficient surveillance program may result from these modifications.

Introduction: Asian sex workers are a significant part of the Australian sex industry. Criminal laws, racism, isolation, poor English language skills and stigma and discrimination combine to increase the vulnerability of Asian sex workers in Australia. To inform service delivery and potential legislative reform, we undertook a study of sex worker health and safety in Western Australia with a focus on Asian sex workers. Methods: This was a mixed methods study in which peer researchers played an essential role. We undertook a survey (available online and in paper form and translated into three languages other than English), semi-structured interviews with sex workers, and interviews with key advisors. Results: In our study, Asian sex workers were older, had lower levels of education, more likely to have sex work as their main source of income, work longer hours and work exclusively in a shop-front massage parlor compared to their non-Asian counterparts. The vast majority of Asian sex workers in our study said they had poor English language skills and the greatest proportion spoke Chinese languages. Sex work had a positive impact on the well-being of many respondents, and their level of psychological distress was similar to the general Australian population. Stress and "bad clients" were common negative impacts of sex work. Asian study participants were less likely than their non-Asian counterparts to smoke, undertake risky drinking or use illicit drugs. A similar proportion of Asian sex workers reported being assaulted compared to their non-Asian counterparts. Discussion/Conclusion: The major challenges facing Asian sex workers in WA seem to be stigma and discrimination, stress, social isolation, and confusion about their legal standing leading to a fear of authorities, particularly the police. Our findings support the need for enhanced targeted peer-based health promotion outreach services for Asian sex workers, increased Asian language services in sexual health clinics and decriminalization of sex work.

Objectives: To determine if patients with cleft lip and/or palate (CL/P) from a Western Australian (WA) cohort were more dissatisfied with their body esteem than a normative non-cleft cohort, and identify demographic variables that may have significant associations with body esteem., Design: Questionnaire study using the Body-Esteem Scale (BES) and Cleft Research Questionnaire (CRQ)., Participants: Self-selected participants from a Western Australian CL/P population across 3 age groups (n=359)., Main Outcome Measures: The BES is comprised of 3 factors: BE-Appearance, BE-Weight and BE-Attribution. Study mean BES factor scores were compared to normative non-cleft scores. Regression analysis was used to determine significant associations within each age group between BES factor scores and CRQ variables of: gender, self-reported body weight category, cleft type and importance of facial appearance rating., Results: Study mean BE-Attribution scores were significantly lower than the normative scores and significantly lower than the mean BE-Appearance and BE-Weight factor scores within the same age groups of this study. Having a cleft type of lip and palate, being overweight, and placing a high importance on facial appearance had significant negative associations with BES scores. Maintaining a normal body weight and placing a lower level of importance on facial appearance had significant positive associations. Gender had no significant associations., Conclusion: In this study, the attribution aspect of body esteem had a greater negative impact on patients than their appearance and body weight. This has important implications for clinical treatment and support of patients.

Clostridium difficile infection (CDI) is primarily associated with hospitalised patients, however, community-associated CDI (CA-CDI) has increased in Australia. We aimed to investigate the epidemiology and outcomes of CA-CDI cases presenting to hospital emergency departments in Western Australia (WA). A retrospective case-control study of CA-CDI cases presenting at six emergency departments in WA from July 2013 to June 2014 was performed. Clinical signs, recent medication, hospitalisations and potential risk factors for CA-CDI were investigated for cases (n = 34) and unmatched controls (n = 62) who were infected with another gastrointestinal pathogen, including Campylobacter spp., Salmonella spp., Aeromonas spp., Shigella sonnei and Escherichia coli O157. Elevated white cell count (31.3% vs 8.2%, p < 0.01), female gender (67.6% vs 41.9%, p < 0.05), age ≥65 years (41.2% vs 21.0%, p < 0.05) and antimicrobial use in the previous month (41.2% vs 11.3%, p < 0.01) were significantly more frequent among cases compared to controls. After multivariable analysis, antibiotic use (odds ratio 8.49, 95% confidence interval 2.75-26.21) and age ≥65 years (3.03, 1.05-8.75) were significantly associated with CA-CDI. Ribotype (RT) 014/020 was most common (40.7%) among 27 C. difficile isolates followed by RTs 002 (14.8%), 001, 056 and 244 (all 7.4%). CA-CDI was associated with advanced age and recent antibiotic use compared to those infected with other gastrointestinal pathogens. RT 014 has also recently been found at high prevalence in public lawn spaces, and previously RT 014 strains from humans and pigs in Australia were closely genetically related, suggesting CA-CDI may be linked with these community reservoirs., (Copyright © 2017 Elsevier Ltd. All rights reserved.)